- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,344.23 / $4,897.79
| Facility | | $1,513.56 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $3,388.44
| Professional | | $1,380.38 | $1,584.89 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $40,738.03 / $57,543.99
| Facility | | $16,982.44 | $40,738.03 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,454.71 / $3,801.89
| Professional | | $1,318.26 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,412.54 / $1,513.56
| Facility | | $1,288.25 | $1,412.54 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $4,265.80
| Professional | | $1,380.38 | $2,041.74 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $2,818.38
| Professional | | $1,230.27 | $1,778.28 | $2,818.38 |